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Ask the Doctor

By Dr. Jack Burks
Chief Medical Officer for MSAA

Dr. Jack Burks

Important note: While Dr. Burks is able to provide helpful information in response to the various medical questions sent in by readers, he is not able to give specific medical advice or offer any type of diagnosis. This may only be done through one's own physician, and this is often stated within the answers.

Q: Six years ago I developed trigeminal neuralgia (causing facial pain). Since that time, I have had ringing in my ears, dizzy spells (lasting from seconds to hours), and I have an electric shock-like pop in my head. I also have a strange visual syndrome, where over the course of an hour, I lose my center vision, followed by my vision becoming blurry and shaky, before clearing up from the center out. Then I am left with pressure and a small headache. I have come to think that these things may not be caused by my neuralgia. Could you please advise me?

A: You are right. The other symptoms described are not typical of trigeminal neuralgia. Therefore, I suggest seeking other possible diagnoses from your doctor. For example, temporomandibular (TM) disorders (also known as TMJ or TMD) refer to problems in the joints of the jaw and its movement, causing pain and other symptoms. TM disorders and migraine/vascular headaches are examples of diagnoses that the doctor may consider. As you know, I am not able to make diagnoses in this column. Please talk to your doctor about other possibilities. If you have MS, which is one cause of trigeminal neuralgia, an MRI might show other MS lesions to explain some of the symptoms.

Q: I have seen several neurologists and have had extensive testing, but have yet to receive a diagnosis. My symptoms include: heat sensitivity; intention tremors; balance problems; double vision; voice problems; and cognitive issues. Some symptoms come and go. Brain and spinal MRIs have been negative; a spinal-fluid analysis showed two oligoclonal bands (with a slight amount of blood). The last neurologist suggested that even if I had lesions, my symptoms are too symmetrical to be MS. Could this be true, and do you have any thoughts on my situation?

A: The diagnosis of MS is usually dependent on the history of certain characteristics of neurological symptoms and specific findings during a neurologic examination. The MRI and spinal-fluid analysis are tests used to help confirm such suspicions. For example, the MRI shows MS-type lesions in more than 90 percent of MS patients after a few years. Your negative MRIs makes it less likely, but not impossible, for you to have MS. The fact that your spinal fluid was contaminated with blood makes the interpretation of that test more difficult.

Time will tell if you have MS. However, your symptoms are troubling, and these can certainly be investigated and treated now, without a definite diagnosis. For example, cognitive issues can be evaluated by neuropsychological testing, and may be addressed through different types of cognitive intervention. Similarly, balance problems can be evaluated and addressed by a balance expert. Voice problems can be evaluated and treated by a speech and language therapist. Double vision can be evaluated by an eye doctor, who may be able to offer some strategies to help you cope with this symptom. Last, MS symptoms are usually not completely symmetrical, since MS brain and spinal-cord damage is not symmetrical. Your doctor's neurological examination may have led him or her to this conclusion. Another MRI and spinal tap may be warranted in the future, if your doctor recommends them.

Q: I broke my arm, wrist, and both legs a few years ago. My left leg now has a plate with screws in it. How can I get an MRI of my spine? Can it be done at all?

A: This is a specific question for your orthopedic surgeon and your MRI center. The feasibility of being able to perform an MRI depends on the material in the plates and screws. Some materials have magnetic properties, but most do not.

Q: During an exacerbation, I have times when my heart rate has slowed down to fewer than 50 beats per minute. Conversely, I have also experienced a racing heartbeat of about 120 beats per minute; this typically occurs in the evening, after my last dose of Ritalin. I tend to have these changes in heart rate when I've done too much and am worn out. Can heart rate be affected by MS, or might this be a side effect of certain medications?

A: Heart rate is not usually directly affected by MS. However, I have seen some MS patients with rapid heart rates that needed investigation. Your rapid heart rate after Ritalin ® (methylphenidate) may be related to your medication. Fatigue, stress, and other stimulants (including caffeine and nicotine) can also affect heart rate. I would ask your doctor about other possibilities. Certain cardiac conditions such as superventricular tachycardia (SVT) should also be considered.

Q: The following two letters were received by Dr. Burks in regards to itching (as a symptom of MS) and its treatment. Dr. Burks' response to these letters is shown below.

1) I was diagnosed with MS in February of 1999 at the age of 31. I have had itching since I was nine years old. No one could find a reason, but the drug Atarax was prescribed. Whenever I had an itch attack, I would take a pill. I never went anywhere without this medication. My itching would disappear for months and then start again. There was no pattern, no tests, no reason... just the itches. I have not had itching since I was placed on Copaxone.

I do not know if one is related to the other. I can tell you that relief comes within 22 minutes from taking one Atarax pill.

2) In the Fall 2007 Issue of The Motivator, a person with MS was experiencing attacks of severely itchy skin. My mother has MS, and one of her doctors prescribed 20 mg of Geodon for this symptom. The medication eliminated her itching problem.

A: For itching, I evaluate for a drug or other allergic reaction. Then, I use moisturizing cream and make certain that fingernails are kept short to avoid more skin irritation from scratching. Also, antihistamines such as Benadryl ® (diphenhydramine) or Atarax® (hydroxyzine) can be used at bedtime if the itching keeps people awake. However, they make many people drowsy. Some non-drowsy products are also available, and I advise readers who experience itching to consult their doctor or pharmacist to learn more about these products.

I am happy to hear that the Atarax pill has provided consistent relief for the individual who wrote the first letter. Copaxone ® (glatiramer acetate) is an effective drug for MS, but its role in treating itching, which has been present for this person since age nine, is an unknown to me.

Regarding the second letter, I do not use Geodon® (ziprasidone) for itching, so I cannot discuss it specifically. Geodon is a drug that is usually prescribed for psychiatric conditions and has its own side effects, including an allergic reaction with itching as a symptom. In any event, I am pleased that the writer's mother has been able to eliminate her itching by using this medication.

Q: I would like to know if there is a form of MS that causes tumors. I have relapsing-remitting MS and I was told by someone that this happens sometimes. Is this true?

A: Can MS patients also have tumors? Yes. However, they may not be specifically related. MS is a disease affecting more than a million people worldwide. With this many people, they get many other medical conditions as well. The occurrence of MS and tumors in the same patient is unusual. Therefore, I would not be overly concerned that you will get a tumor as well as MS. However, science and symptoms of a tumor, such as rectal bleeding, the increasing size of a mole, and unexplained weight loss, should not be ignored.

Q: Does anyone in the medical MS community have experience with the specific area of oral cancer in patients who also have MS? What are some special concerns that a person with MS undergoing cancer treatment needs to be aware of? I've read that in some instances, chemotherapy has been used to treat MS. Also, are you aware of any experimental/non-traditional therapies for treating oral cancers in patients with MS?

A: As mentioned earlier, any tumor can occur with MS as well as for the general population. The symptoms of oral cancer can overlap with some MS symptoms. For example, trouble with swallowing, speech, and salivation can be seen in both conditions. A speech and language therapist who is knowledgeable with both conditions can be helpful.

If radiation is necessary near the throat, care will be taken to reduce radiation damage to the nearby nervous system. Radiation oncologists are aware of these issues.

Cancer chemotherapies, such as Novantrone® (mitoxantrone), Imuran® (azathioprine), and methotrexate, are used for MS treatments, when other MS therapies have shown suboptimal responses. Other cancer drugs may also help MS patients, but have not been tested adequately. Your oncologist may have more specific insights into your specific cancer drug and its potential effects on MS. Since the combination of oral cancer drugs and MS is so unusual, your doctors may wish to consult with a major cancer center and/or MS center for more specific advice in your situation.

I am not aware of any experimental or nontraditional therapies that are being used specifically for oral cancer and MS.

Q: Are viruses involved with MS?

A: A number of viruses and other infectious agents (such as chlamydia) have been incriminated as possible causes of MS. These are still viable theories. The current leading candidate is the Epstein-Barr virus, which is associated with mononucleosis. More than one virus may be involved, and the cause of MS is likely multi-factorial. Regardless, MS is not a contagious disease. Could a virus-related vaccine be developed for MS? Possibly, but more research needs to be conducted.

To Submit Questions to Ask the Doctor...

If you have a question that you would like to ask, please submit your question to:

Readers may also send in questions via email to aborkowski@mymsaa.org. Please be sure to write "Ask the Doctor" in the subject line.

Jack Burks, MD, is a neurologist, chief medical officer for MSAA, clinical professor of neurology at the University of Nevada in Reno, Nevada, and member of the Clinical Advisory Committee of the NMSS. He has edited two MS textbooks. Previously, Dr. Burks established the Rocky Mountain MS Center and has served on several Boards of Directors, including the American Society of Neurorehabilitation (past president), the Colorado Neurological Institute, the American Academy of Neurology, and the Consortium of MS Centers. In recent years, he has lectured in more than 30 countries.